While states such as Arkansas and Iowa have negotiated deals with the federal government to pursue flexible approaches to Medicaid expansion, Daugaard hasn’t shown the same urgency.

“I have not pressed (the federal government) about that,” Daugaard said Tuesday after his State of the State speech. “I thought it is more sensible to let some of the pressure that they’re under right now play out a little, give them some time to get some of what they’re already trying to do in order, and then approach them to see about a waiver.”

Daugaard’s goal is to get approval to cover only South Dakotans earning below 100 percent of the federal poverty line — $10,890 per year for a single person, or $22,350 for a family of four. The federal health care law calls for states to expand Medicaid up to 133 percent of the federal poverty line. That’s $15,282 for a single person or $31,322 for a family of four.

The distinction is important because a drafting error in the law means individuals earning between 100 and 133 percent of the poverty line are eligible for health insurance subsidies through the law’s online marketplaces. But those below 100 percent, who were intended to be put on Medicaid, aren’t eligible for the subsidies.

An earlier request from Daugaard to cover only South Dakotans below 100 percent was denied.

Daugaard said he didn’t want to be too aggressive in pushing for alternatives.

“I’ve already asked the question and been denied. The question is, how hard do you press?” Daugaard said. “That’s a judgment that one must make. If you get the wrong answer and you continue to press, sometimes the one giving you the answer digs in deeper. I think it’s worth being careful and being patient.”

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Other states

Supporters of Medicaid expansion, such as Dave Hewett, think Daugaard should take a hard look at states such as Iowa and Arkansas. They were allowed to use money for Medicaid expansion to pay for private health insurance for people eligible for Medicaid.

“There are states surrounding South Dakota that have acquired waivers and used public-private partnerships,” said Hewett, president of the South Dakota Association of Healthcare Organizations. Pursuing a waiver could be an opportunity to expand health coverage and reform the state’s Medicaid system, he said.

“What a great opportunity to cover more people with a better system,” Hewett said.

'Best approach'

“I am doing what I believe is the best approach to dealing with the vulnerable populations that we have,” Daugaard said.

He singled out one subset of South Dakota’s low-income residents as his particular focus.

“In my estimations ... the most vulnerable citizen today is the single parent with children who are at 100 percent of poverty or lower,” he said. “It’s hard for that single parent with children to get above that 100 percent level.”

Of the roughly 25,000 uninsured South Dakotans who earn below 100 percent of the poverty line, about 18,000 are single adults, according to data provided by the South Dakota Department of Social Services. About 7,000 are parents with children.

Under South Dakota’s Medicaid guidelines, those children already are covered by Medicaid, but their parents receive coverage only if they earn less than 52 percent of the poverty line — $6,756 for a single person, or $10,620 for a family of four.

Someone without children can rise above the poverty level by working 30 hours a week at minimum wage. Because of that, Daugaard said he isn’t as concerned about covering low-income earners without children.

“It’s a matter of choice, most of the time,” he said, “unless they’re of limited ability or have some sort of an issue that doesn’t qualify them as disabled but somehow limits their ability to get work.”

But Hewett argued that if the state can afford to cover somebody, it should, regardless of how many hours they work.

“Just because people are working part time doesn’t meant they aren’t contributing to society,” Hewett said.

Democrats and a few Republicans in the Legislature have urged Daugaard to expand Medicaid.

“Medicaid expansion is probably the single best thing we could do for economic development and workforce development in South Dakota,” said House Democratic leader Bernie Hunhoff of Yankton. “The return on investment is enormous. The amount of money that it would infuse in the state’s economy is a staggering amount. It’s all about making sure that young, working adults are healthier.”